1
Moderators and predictors of outcomes in telephone delivered compared to face-to-face
cognitive behaviour therapy for pediatric obsessive-compulsive disorder: Preliminary
evidence from a non-inferiority RCT
Authors:
Nair A1 ,Turner C2,3, Heyman I4, Mataix-Cols D5, Lovell K6, Krebs G7, Lang K7, Byford S7,
O'Kearney R1*
1 Research School of Psychology, Australian National University, Canberra
2 School of Psychology, Australian Catholic University, Brisbane
3 The University of Queensland, Brisbane
4 University College London, Great Ormond Street Institute of Child Health, London, United
Kingdom
5 Karolinska Institutet, Sweden, & Stockholm Health Care Services
6 University of Manchester, United Kingdom
7 Institute of Psychiatry, Kings College London
*Correspondence: Professor Richard O’Kearney, Research School of Psychology, Australian
National University, Canberra, ACT 0200, Australia. [email protected] Tel + 61
2 6125 8125. ORCID: 0000-0002-7839-7920
Word Count (excluding tables): 4, 100
Running head: Moderators of telephone v face-to-face CBT for pediatric OCD
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Funding Acknowledgement
The research trial of TCBT compared with face-to-face CBT was funded by the National
Institute for Health Research (NIHR) under its Research for Patients Benefit (RfPB)
Programme (grant reference number PB-PG-0107-12333). The views expressed are those of
the authors and not necessarily those of the NHS, the NIHR, or the Department of Health.
Acknowledgements
The authors wish to thank the NHS Mental Health Research Network for assistance with
recruitment of participants to this study. The authors wish to thank Chloë Volz, C.Psychol,
Kristina Hilton, DPsy, Jacinda Cadman, M.ClinPsy, Holly Diamond, D.Psy, Amy Shayle,
D.Psy, Amita Jassi, D.Psy, and Caroline Stokes, D.Psy, of the South London and Maudsley
NHS Foundation Trust, for their contributions to this project.
3
ABSTRACT
This study provides a preliminary exploration of factors which differentially predict treatment
response to telephone delivered cognitive behavioural therapy (TCBT) compared to face-to-
face CBT (CBT) in a randomised non-inferiority controlled trial of 72 children (aged 11 to 18
years) with obsessive compulsive disorder (OCD). Potential moderator variables, their
interaction with treatment group (CBT, TCBT), and baseline levels of OCD severity were
entered into separate regression models where the primary outcome measure was the post-
intervention Children’s Yale Brown Obsessive Compulsive Scale total score (CYBOCS).
Separate regressions were also used to test associations between predictors and outcome
controlling for pre-treatment CYBOCS. Only pre-treatment level of parent-rated child peer
problems moderated the effects of the two interventions on CYBOCS severity at post-
treatment (β = 3.63; p = 0.05; CI = 0.04 to 7.31). Peer problems scores were negatively
associated with post-intervention CYBOCS in TCBT (r = -.42; p = 0.02; CI -0.70 to -0.04)
but not in CBT (r = -0.12; p = 0.56; CI -0.51 to 0.31). After controlling for baseline
CYBOCS, only family accommodation rated by mothers predicted poorer outcomes in both
groups (r = .40; p <0.01; CI = 0.10 to 0.41). While CBT and TCBT may be equally effective
for adolescents with OCD, the current results tentatively suggest that higher baseline level of
peer problems strengthened the response to therapy for youth receiving TCBT. The result for
the predictor analyses reinforce the importance of directly addressing family accommodation
during CBT for pediatric OCD regardless of delivery mode. Limitations of the current
findings and directions for future work are discussed.
Keywords: adolescent, obsessive compulsive disorder, cognitive behavior therapy,
moderators, predictors.
4
Moderators and predictors of outcomes in telephone delivered compared to face-to-face
cognitive behaviour therapy for pediatric obsessive-compulsive disorder: Preliminary
findings from a non-inferiority RCT
Pediatric obsessive compulsive disorder (OCD) is a severe, often debilitating mental
illness with estimated prevalence rates between 0.5 and 2% [1,2]. The intrusiveness and time-
consuming nature of OCD can have a particularly pernicious impact on children and
adolescents as they are still forming their self-identity and developing social and educational
skills [3,4]. A review of long term outcome studies reported that 41 to 60% of children with
OCD continue to have moderate to severe OCD in adulthood [5]. Moreover, earlier age of
onset and longer duration of illness are significant risk factors for persistence, highlighting
the critical need for the development and dissemination of evidence-based interventions for
OCD presenting in children and adolescents [5,6]. Randomised controlled trials have
consistently found that cognitive behavioural therapy (CBT) incorporating exposure with
response prevention (E/RP) for pediatric OCD is as effective as selective serotonin reuptake
inhibitors (SSRIs), and may optimise therapeutic outcomes when combined with SSRIs [7,8].
Because of its lower risk to benefit ratio, practice guidelines recommend CBT alone as the
first line intervention for mild to moderate OCD and CBT in combination with medication
treatment for more severe/treatment resistant OCD [9,10].
Despite these findings, many children and adolescents with OCD are not able to
access CBT because of the restricted availability of appropriately trained clinicians in outer
metropolitan and non-urban areas, and the financial costs of access to therapy [11]. Remote
delivered CBT programmes for OCD such as telephone, web-camera or internet CBT have
been suggested as valid alternatives to face-to-face CBT (CBT) because of their convenience,
time and cost-effectiveness, and perceptions of being less stigmatising [12]. Trials involving
5
such remote interventions for youth with OCD have found significant post-treatment
reductions in OCD severity comparable to face-to-face CBT [12,13,14]. A recent randomised
control non-inferiority trial which compared telephone delivered CBT (TCBT) and standard
face-to-face CBT for children and adolescents with OCD found that both delivery modes
produced substantial post-treatment reductions in OCD severity which were sustained over
12 months, and that the benefits of TCBT were not inferior to CBT (non-inferiority margin 5
points on Child Yale Brown Obsessive-Compulsive Scale) [15].
These results indicate that CBT for OCD in children and youth can be delivered
remotely without reducing its efficacy, opening the way to making CBT available in the
broadest range of circumstances. While this evidence supports the conclusion of equivalent
efficacy of TCBT and CBT at the group level, it is important to acknowledge that the
adaptation of CBT for telephone delivery does modify aspects of therapeutic processes such
as the therapist’s sensitivity to levels of affect which, for certain young people, may diminish
or augment their benefits. Identifying pre-treatment characteristics of the child/adolescent,
their disorder or environmental context that predict a differential benefit from TCBT or CBT
has important implications for treatment assignment and improving the likelihood of
therapeutic success [16,17]. Preliminary research on moderators for remotely delivered CBT
compared to CBT for adults with social anxiety disorder and depression, for example, has
found that higher baseline levels of anxiety or depressive symptoms, and co-morbidity with
other emotional disorders, were associated with less favourable outcomes in the remotely
delivered CBT group but not in face-to-face CBT [18,19,20]. While some studies of CBT for
pediatric OCD suggest that patients with a co-morbid anxiety disorder do better with face-to-
face CBT (compared to a waitlist control) than their peers without a co-morbid anxiety
disorder [21], as far as we are aware there is no evidence about possible moderators of the
relative benefits of CBT versus remotely delivered CBT for pediatric OCD. It is important,
6
given the rapid advance of technological applications of CBT, to develop an evidence base
about factors which may predict a superior benefit from face-to-face or remotely delivered
CBT for pediatric OCD, which can assist clinicians in making the best recommendations for
their patients as well as focus researchers on areas for which modifications of CBT are
required.
The aim of the current study was to examine factors which may moderate the relative
efficacy of CBT compared to TCBT for pediatric OCD using data from a randomised
controlled non-inferiority trial [15]. In addition to level of co-morbid internalising symptoms
(depression and emotional symptoms) which have been shown to moderate remote delivery
of CBT efficacy for adult anxiety disorders relative to face-to-face CBT [19, 20], the study
explores the demographic, OCD related, other co-occurring problems and family factors
which were measured at base-line as moderators of the post-treatment outcome in TCBT
relative to CBT. A secondary aim of the study was to identify potential predictors of CBT
outcome. Knowledge of factors that are associated with an attenuated treatment response can
help identify children and adolescents who may benefit from additional or more intense
therapy in order to maximise outcomes [16,17] and also assist researchers in specifying
factors worth further examining as effect moderators [16]. In a recent systematic review [22]
we reported consistent evidence across multiple trials of CBT in children and adolescents
with OCD that age, severity of pre-treatment OCD-related impairment, level of co-existing
externalising and internalising symptoms, and family accommodation of OCD symptoms
were predictors of poorer response to treatment. In the current study we examine these factors
as predictors of post-treatment OCD symptoms for children and adolescents in both the
TCBT and CBT groups.
7
Method
This study presents an analysis of existing data from a randomised non-inferiority trial
comparing CBT and TCBT for OCD in child and youth aged 11 to 18 years [15].
Participants
Participants in the trial were recruited through referrals to a specialist OCD clinic
between 2008 and 2011 by general practitioners and mental health professionals within the
UK National Health Service. The sample consisted of 72 adolescents, between the ages of 11
to 18 years, who met Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition
Text Revision (DSM- IV-TR) criteria for a primary diagnosis of OCD, and who had a
Children’s Yale-Brown Obsessive Compulsive Scale (CYBOCS) score of 16 or higher
(suggestive of moderate to high severity). Primary diagnosis was established an experienced
clinical team following a CYBOCS assessment and parent and child completion of the
Anxiety Disorders Interview Schedule for Children (ADIS-IV-C/P) (see [15] for full
methodological details). Additional inclusion criteria were: a medication free status or having
a stable dosage of medication for at least 12 weeks; consenting to random assignment; and
parental involvement in the intervention. Individuals with suicidal ideation, severe medical
illnesses or neurological impairments, current psychosis or substance abuse or dependence,
poor English language comprehension, learning disabilities or pervasive developmental
disorders were not included.
Measures
Children’s Yale-Brown Obsessive Compulsive Scale (CYBOCS) [23]. The CYBOCS
is a clinician administered instrument that assesses the severity of obsessive and compulsive
symptoms over the previous week. The CYBOCS total score has demonstrated robust
8
psychometric properties with strong internal consistency (Cronbach α = 0.90) and a test re-
test reliability intra-class coefficient of 0.79 [24]. Internal consistency in this sample was
sound (α = 0.88).
The Children’s Global Assessment Scale (CGAS) [25]. The CGAS is a clinician rated
assessment which measures overall adaptiveness and general functioning. Lower scores
reflect a greater level of impairment. Interrater reliability correlations range from .59 to .90,
with greater consistency between experienced raters [26].
Beck’s Depression Inventory-Youth (BDI-Y) [27]. Depression in participants was
measured using the 20 item self-report youth version of the BDI. The BDI-Y has high
internal consistency (Cronbach α = .90) and test re-test reliability coefficients from .74 to .93
[27,28]. Internal consistency in this sample was strong (Cronbach α = .89).
The Strengths and Difficulties Questionnaire (SDQ) [29]. The SDQ is a 25 item
measure that assesses internalising (emotional) symptoms, conduct problem and interpersonal
concerns. It provides an overall problem score as well as scores on 4 problem subscales
(conduct symptoms, emotional problems, peer problems, hyperactivity/inattention problems)
and a pro-social behaviour subscale. The SDQ’s internal consistency Cronbach α has been
reported at .73 and mean temporal stability over 4 to 6 months was found to be .62 [30]. The
current study uses the parent report version of the SDQ. The internal consistency for this
sample ranged from low to excellent, with internal consistencies ranging from α = .38 to α =
.91 (emotional problems α = .91; conduct problems α = .38; hyperactivity α = .72; peer
problems α = .71; prosocial behaviour α = .68; SDQ total difficulties α = .77).
The Family Accommodation Scale-Parent Report (FAS-PR) [31]. The FAS-PR is a 13
item measure of familial accommodation of a child’s OCD related behaviours over the
previous month. The instrument has good internal consistency (α =.90) and convergent and
9
discriminant validity [32]. The report on the FAS-PR from both the mother and father were
used. Internal consistency for father FAS (α =.89) and mother FAS (α =.91) in this sample
was excellent.
The Depression Anxiety and Stress Scales (DASS) [33]. Levels of depression, anxiety
and stress in parents was measured using the DASS, a 42 item self-report questionnaire that
assesses features such as low positive affect, hopelessness, low self-esteem, autonomic
arousal and tension [33]. The DASS demonstrates strong reliability (Cronbach = 0.96 for the
total score) and good construct validity [34]. Internal consistency for the total DASS score in
this sample for father DASS (α =.92) and mother DASS (α =.97) was excellent.
Procedure
Putative moderator or predictor variables were measured at pre-treatment and prior to
randomisation [15] while the post-treatment outcome measure was administered immediately
after the intervention. The assessors of outcomes were blind to treatment group and pre-
treatment characteristics. The CBT intervention protocols in both conditions were identical
apart from the mode of delivery (face-to-face, n = 36; telephone, n = 36) and consisted of 14
sessions that were completed within 17 weeks. The first two sessions addressed establishment
of rapport and psychoeducation; sessions three to twelve were primarily devoted to E/RP
using hierarchies and cognitive strategies; the final two sessions focused on relapse
prevention. Participants were assigned daily homework E/RP tasks in accordance with their
progress on the hierarchies. The length of sessions varied slightly, but were typically 45-60
minutes long, with 35-45 minutes allocated to therapy with the young person and an
additional 10-15 minutes to work with parents. The session time with parents provided them
an overview of the session, explained homework assignments and their rationale, and gave
10
them the opportunity to clarify potential doubts. Treatment across both conditions was
delivered by clinical psychologists experienced in working with childhood OCD.
Ethics statement
The study was approved by the Joint South London and Maudsley / Institute of Psychiatry
Research Ethics Committee (08/H0807/12) and in accordance with the ethical standards laid
down in the 1964 Declaration of Helsinki and its later amendments. Written informed consent
was obtained from all parents and participants over 16 years, and informed assent from
participants under 16 years after a detailed description of the study had been given. The trial
was registered on the International Standard Randomized Controlled Trial Number Register
(ISRCTN27070832).
Data analysis
Independent samples t-tests were used to examine pre-intervention between group
differences (TCBT v CBT) in the outcome and potential moderator/predictor variables.
Little’s Missing Completely at Random (MCAR) test confirmed that the data was missing at
random [35]. Of the 72 participants, 4 did not complete the post treatment CYBOCS. These
cases were excluded from the moderator and predictor analyses. The moderator analyses
involved running separate multiple regression models for each potential moderator variable
with post-treatment total CYBOCS score as the outcome variable. Separate regression
models were used because at this stage in our knowledge, when there is little information
about possible effect moderation between different modes of delivery in CBT, it is more
important to identify putative moderators rather than control for interrelationships between
the variables. Each model entered baseline CYBOCS score, the baseline score of the potential
moderator variable, group (CBT, TCBT), and an interaction term (group x moderator) as
independent variables in a single block. If the interaction term was significant (p < 0.05), a
11
subsequent simple slope analysis was conducted using split file partial correlations (split by
group) controlling for baseline CYBOCS score. The values for potential moderator variables
were grand mean centred if they were continuous and dummy coded if they were categorical.
Due to the sample size, limited power and lack of a priori predictions for most variables,
moderator analyses were considered exploratory in nature and type 1 error was set at α =
0.05. Values of each estimate, p value and 95% confidence intervals are reported.
Associations between each pre-treatment factor and the level of CYBOCS were
estimated using Pearson correlations for the total sample. Because of the large number of
variables, only those that had first order Pearson correlations with post-intervention
CYBOCS scores higher than 0.20 were further analysed as potential predictors in separate
regression models. This value was chosen because, given the sample size of 72 and power of
.8, only first-order correlation above .20 were likely to be significant (p < .05) in partial
correlation. This allowed exploration of variables which had a moderate strength of
relationship with the outcome while reducing the number of analyses performed. The
regression analyses were run with the potential predictor variable in the first block as an
independent variable and both the individual potential predictor variable and baseline
CYBOCS scores in the second block as independent variables (to identify predictors before
and after partialling out the association of baseline CYBOCS to post-treatment score). Most
previous paediatric OCD predictor studies have not controlled for baseline OCD severity
[16]. Post-treatment CYBOCS scores were collapsed across treatment conditions to examine
predictors of treatment response; interaction effect and subsequent simple slopes analysis
allowed examination of differential strength of predictions between groups.
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Results
Table 1 presents the baseline demographic and clinical characteristics of participants
within each of the treatment groups. Of the 72 participants, 68 (94% percent) completed the
CYBOCS at the end of the 14 session intervention. The average age at baseline was 14.35
(SD = 2.12). The gender split was (female = 45.8%; male = 54.2%). The mean CYBOCS
score at baseline was in the moderate to severe range for both groups (CBT M = 25.03; SD =
4.23; TCBT M = 25.28; SD = 4.05). The CBT group had significantly higher average baseline
scores than the TCBT group on SDQ total score (p = 0.02; mean difference = -2.75; CI = -
5.07 to -0.42) and SDQ conduct subscale scores (p = 0.04; mean difference = -0.82; CI =-
1.62 to -0.18; Table 1). No other between-group differences at baseline were significant.
With a non-inferiority margin of 5 points on the CYBOCS, TCBT was judged to be not
inferior to CBT on the primary outcome at post-treatment [15], and on the secondary
outcome (SDQ; BDI-Y) using a one standard deviation non-inferiority margin [15].
The results of the moderator analyses are summarised in Table 2. Neither the group
by BDI-Y interaction nor the group by SDQ emotional problem interaction were significantly
associated with post-treatment CYBOCS. All the other candidate variables evaluated except
for SDQ peer problems and prosocial behaviours showed very small effects. SDQ peer
problems score by group interaction showed a significant association with post-intervention
CYBOCS total (β = 3.63; p = 0.05; CI = 0.04 to 7.31; r = - 0.26). The simple slopes analysis
(Figure 1) showed that SDQ peer problems scores were significantly negatively associated
with post-intervention CYBOCS in TCBT (r = -.42; p = 0.02; CI -0.70 to -0.04) but not in
CBT (r = -0.12; p = 0.56; CI -0.51 to 0.31). The group by SDQ prosocial behaviour score
interaction showed a trend level result (β = 2.02; p = 0.06; CI = -0.08 to 4.14; r = -0.17).
Partial correlations (controlling for baseline CYBOCS scores) between prosocial scores and
post intervention CYBOCS showed a notable although not significant relationship between
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prosocial score and outcome in TCBT (r = -0.35; p = 0.07; 95% CI -0.66 to 0.05) but not in
CBT (r = 0.001; p = 0.97; CI -0.41 to 0.41).
Pearson correlations identified 9 pre-treatment variables which had correlations with
post-intervention CYBOCS scores higher than 0.20 (for both groups of participants
combined). The results of the regression analyses for these variables are summarised in Table
3. Age, severity of OCD-related impairment and level of mother-report of family
accommodation were associated with poorer post-treatment outcome when baseline
CYBOCS was not controlled. Only level of family accommodation reported by the mother
independently predicted an attenuated response to CBT once baseline CYBOCS was included
in the regression models (β = 0.26; p <0.01; CI = 0.10 to 0.41; r = 0.44; CI 0.03 to 0.50).
While higher peer problems also emerged as a significant predictor of an improved outcome
(β =-1.70; p =0.03; CI = -3.29 to 0.11), this effect was only evident in the TCBT group and
was attributable to the moderation effect previously described.
Discussion
This is the first study to explore potential moderators of treatment outcome between
face-to-face and remotely delivered CBT for pediatric OCD. Using data from a randomised
controlled non-inferiority trial that compared face-to-face CBT with telephone CBT [15] for
11 to 18 year olds with OCD, we examined child characteristics, pre-treatment levels of co-
occurring psychological symptoms and parental factors as potential effect moderators of the
relative benefits of the two modes of delivery of CBT. We found no evidence for the
anticipated inferior benefits from telephone CBT compared to face-to-face CBT related to
higher levels of co-occurring internalising problems such as depressive symptoms or anxiety
found in some adult studies [19,20]. Our results did indicate, however, that higher level of
parent-reported peer problems shown by the adolescent at baseline was negatively related to
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post-intervention OCD severity scores in the telephone delivered CBT, but was unrelated in
face-to-face CBT. There was no evidence that any other pre-treatment variables significantly
moderated treatment outcome between the two versions of CBT.
It is not clear what accounts for the moderate relationship between level of peer
problems and treatment outcome for youth receiving TCBT, which is not evident when CBT
is delivered face-to-face. As the non-inferiority trial included a number of factors to monitor
and ensure integrity of the treatment within and across the two modes of delivery, such as
using a detailed therapist manual, supervision by experienced therapists, and independent
ratings of treatment integrity, it is unlikely to be explained by a different response by
therapists in the telephone delivered CBT to youth with peer difficulties. There is some
qualitative evidence from a study of adults receiving CBT over the telephone [36] that some
participants indicated a preference for remote delivery as they felt better able to develop a
closer therapeutic alliance when they were less distracted or pressured by the therapist’s
physical proximity. The moderating effect of peer problems observed in the current study
may be attributable to a similar factor such that youth who have interpersonal difficulties
experienced reduced discomfort in telephone CBT, which facilitated their alliance with the
therapist and strengthened the response to CBT for these participants.
Another possibility may be that peer problems arise, in part, from social anxiety and
that youth with social anxiety symptoms responded positively to the telephone condition. We
were unable to examine this as a specific measure of social anxiety was not included,
however future research addressing this question would be of benefit. However, there was no
difference in therapeutic alliance was observed between conditions and no evidence of a
negative association of peer problems to outcome in face-to-face CBT, and The interaction of
level of the child or adolescent’s prosocial behaviour and treatment had a similar size effect
as peer problem, albeit not significant (p =.06). This pattern of results for the moderator
15
analysis suggests that delivery of CBT for OCD in children and youth over the phone may
activate some specific interpersonal factors which influences the treatment response. The
current findings clearly raise the question of whether the variability in the interpersonal
contexts between telephone, and perhaps other remote methods of delivery, and face-to-face
delivery needs to be considered further in order to better understand how to provide the best
treatment recommendation for individual patients and their families.
The inconsistency between the present results, and data from adult studies which have
reported reduced TCBT effectiveness with higher levels of co-morbid internalising problems
for adults with social anxiety disorder or depression [18, 19, 20], can be explained by a
number of factors. In particular, the adult studies involved one-to-one delivery of CBT while
CBT for paediatric OCD in the current study included family involvement. The inclusion of
the family may have countered any impact of depressive symptoms on the adolescent’s
motivation for treatment in telephone CBT. The adult studies recruited participants who had
co-morbid anxiety disorders in addition to their primary diagnosis [18,19] while, in the
current study, participants had a primary diagnosis of OCD and their internalising symptoms
were secondary in nature. In addition, a number of methods were put in place in the current
study [15] to ensure a consistent and proper intensity of CBT was provided across the two
modes of delivery. Overall, while the current finding is preliminary given the exploratory
nature of the study, it suggests that youth with OCD respond equally well to the current best-
practice CBT delivered face-to-face or over the telephone, regardless of their level of pre-
treatment depressive or anxiety symptoms.
The finding that the level of family accommodation at pre-treatment did not moderate
the relative benefits of the two modes of delivery of CBT has important potential
implications. It suggests that additional focus on the mother’s response to her child’s
symptoms may be required to enhance CBT effectiveness generally and that this additional
16
focus may be important for improving CBT efficacy regardless of the mode of delivery. This
pattern of results indicates that the ability for CBT, with a parental component, to reduce the
symptom levels in pediatric OCD is not related to the initial level of family accommodation.
Given the key role of family accommodation in maintaining symptoms, methods aimed at
altering the parent’s responses to their child’s OCD symptoms may be delivered as
effectively remotely as it can be in face-to-face treatment.
A secondary aim of the current study was to identify predictors that impacted
outcome for both treatment modalities. In general, our findings are consistent with those of
other studies of predictors of CBT for pediatric OCD, which indicate that most child factors
which predict outcome are associated with initial OCD symptom severity, and this
interrelationship explains their association with treatment outcome. For example, studies
[37,38] which examined OCD-specific, and general psychological distress concurrently,
found that level of general psychological symptom did not predict outcome of CBT after
controlling for pre-treatment OCD-specific severity. In the current study, only maternal
family accommodation predicted a poorer outcome in both interventions after controlling for
baseline OCD severity. Family accommodation has been associated with higher post
intervention OCD severity scores in previous research [16,37,39]. Although paternal family
accommodation scores were not significantly related to outcome in the current study, fathers
can contribute to the maintenance of OCD symptoms not only by providing excessive
reassurance or acquiescing to symptoms, but also by adding to a climate of criticism around
the display of the compulsions [40,41]. It is important that when family accommodation
levels of either parent are moderate to high, that clinicians directly address this throughout
the intervention to maximise the chances of a positive outcome.
The current study has a number of strengths and limitations. It shares the strengths of
the study from which the data was analysed [15] which include recruitment of a large sample
17
of help-seeking participants with a clear diagnosis of OCD, inclusion/exclusion criteria that
increased the study’s generalisability, relatively low attrition rate (6% of the original sample)
with dropouts missing at random, manualised evidence-based treatment protocols, high
adherence rates in both conditions and the use of psychometrically sound instruments to
assess relevant putative predictors and moderators and the outcomes. Because initial
symptom severity often confounds the true strength of association between predictors and
outcome in treatment studies we present these associations both as first order and partial
corrections controlling for initial OCD symptom severity.
The current findings need to be considered, nevertheless, in light of several
limitations. While the current sample is large enough to test the non-inferiority and prediction
hypotheses, it was not necessarily adequately powered to examine the moderator hypotheses
across two conditions. The non-significant results reported for levels of internalising
symptoms and family accommodation, therefore, do not provide strong evidence for ruling
out these factors from further evaluation as moderators. In addition, because of the small
number of participants in each treatment condition, the unpacking of significant interactions
results in numbers in the simple slopes analysis which are small, having the effect of wide
confidence intervals for the estimate of the strength of association. While significant, we
cannot confidently conclude from the current findings that the strength of the relationship
between level of peer-problems and OCD symptom outcome has notable clinical importance.
We also acknowledge caveats to our analytic approach. Because evidence of
potential moderators of CBT based on mode of delivery is only starting to be gathered in the
adult literature and this is the first study to examine between delivery mode moderators in
CBT for pediatric OCD, we treated the statistical analyses as exploratory and did not adjust
the type 1 error rate or consider the interrelationships between possible moderators in
multiple regression. Our view is that at this stage of knowledge it is important to identify all
18
potential moderators empirically and subsequently test them in properly powered studies. The
main finding for peer-problems reported here needs, therefore, to be considered cautiously
until it and other factors are followed up in further studies examining moderation. Another
caveat to inferences from the findings of the current study is the relevance of the data to the
populations which are most likely to access CBT remotely. The sample included mostly
Caucasian children and adolescents, aged 11 to 18 years, and participants were randomised
rather than preferentially allocated to telephone or face-to-face CBT. While randomisation is
necessary for comparing efficacy, it precludes identifying effect moderators which may be
associated with the family’s preference for one treatment mode of delivery over another when
both are available.
In conclusion, the present paper enhances the findings of the original study [15] by
showing that for children and adolescents with a primary diagnosis of OCD pre-treatment
characteristics associated with co-occurring problems and family characteristics do not
differentially predict the efficacy of telephone CBT and face-to-face CBT Therefore,CBT
over the telephone has the potential to address barriers to appropriate, evidence based care for
the majority of families. The results also suggest a relationship between CBT outcome for
telephone delivery and level of peer problems, such that for children with more peer
problems, telephone delivery may optimise treatment outcome. In addition, the results of the
predictor analyses emphasised the therapeutic importance of explicitly targeting family
accommodation in CBT programs. Further research could address the question of moderators
of telephone CBT and face-to-face CBT using a larger sample size. Similarly, studies
examining moderators of outcome in other remote CBT delivery modalities (such as CBT via
web-cams or internet delivered CBT) would also carry important practical implications.
Finally, alternative methods to identify predictors and moderators of treatment outcome for
CBT, such as machine learning approaches, may provide additional tools to help identify
19
groups of young people with OCD who may be more suitable for remote delivery of care than
traditional in-office approaches [42].
20
Conflict of Interest: The authors declare that they have no conflict of interest.
21
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Table 1 Means (SD) for baseline moderator variables by group (TCBT; CBT); mean difference;
significance and 95% CI
Variable Telephone CBT Mean (SD)
N = 36
Face-to-face CBT Mean (SD)
N = 36
Coefficient Mean
Difference
Significance of Difference (Two Tailed)
95% CI
1. Age in Months
175.75 (25.07) 180.86 (26.95) -5.11 0.40 -17.34 to 7.12
2. Baseline CYBOCS
25.28(4.05) 25.03(4.23) 0.25 0.79 -1.70 to 2.20
3. Age of Onset in Months
133.22(43.84) 132.29(37.86) 0.93 0.92 -18.77 to 20.64
4. CGAS 50.08(9.03) 49.83(9.13) 0.25 0.90 -4.01 to 4.51 5. BDI-Y 16.11(7.71) 19.54(9.85) -3.42 0.11 -7.64 to 0.79 6. SDQ-Total 16.07 (3.79) 18.82(4.81) -2.75 0.02* -5.07 to -
0.428 7. SDQ-
Emotional Symptoms
4.82(2.51) 5.71(2.66) -0.89 0.20 -2.28 to 0.49
8. SDQ-Hyper- activity
4.21(1.72) 4.71(1.69) -0.50 0.28 -1.41 to 0.41
9. SDQ-Conduct Problems
2.32(0.94) 3.14(1.9) -0.82 0.04* -1.62 to -0.18
10. SDQ-Peer Problems
4.71(0.97) 5.25(1.45) -0.53 0.11 -1.20 to 0.12
11. SDQ-Prosocial Behaviour
7.00(1.80) 7.07(2.41) -0.07 0.90 -1.21 to 1.07
12. Biological Relative with OCD
3.38 (1.15) 3.41(1.18) -0.02 0.91 -0.59 to 0.53
13. FAS-Mother Total
19.26(12.21) 18.58(11.91) 0.67 0.82 -5.27 to 6.62
14. FAS-Father Total
11.96(11.43) 9.88(7.74) 2.07 0.48 -3.83 to 7.98
15. DASS Mother Total
20.60(24.21) 15.13(13.73) 5.47 0.25 -4.10 to 15.04
16. DASS Father Total
11.40(11.11) 8.25(6.57) 3.15 0.31 -3.08 to 9.38
Note: CY-BOCS: Children’s Yale Brown Obsessive Compulsive Scale; CGAS: Clinical Global Assessment Scale; BDI-Y: Beck Depression Inventory for Youth; DASS: Depression Anxiety Stress Scale; SDQ- Strengths and Difficulties Questionnaire- Parent Report; FAS: Family Accommodation Scale- Parent Report
28
Table 2 Results of regression for the moderator by group interaction on post-treatment
CYBOCS total, for each possible moderator
Possible Moderator Unstandardized β (Standard
Error)
t p Value
95% Confidence
Intervals
Part Correlations
Demographic Variables Gender 1.53(3.62) 0.42 0.67 -5.70 to 8.77 0.051 Age at Assessment in Months 0.04(0.07) 0.60 0.54 -0.09 to 0.18 0.072 OCD-Related Variables CYBOCS (baseline severity) -0.40(0.44) -0.90 0.36 -1.28 to 0.48 -0.110 Age of Onset in Months 0.02(0.04) 0.52 0.59 -0.07 to 0.12 0.066 CGAS 0.28(0.20) 1.42 0.16 -0.11 to 0.69 0.169 Co-morbid Symptoms BDI-Y -0.05(0.21) 0.79 0.79 -0.49 to 0.38 -0.032 SDQ- Total 0.007(0.53) 0.01 0.99 -1.06 to 1.08 0.002 SDQ- Emotional Symptoms -0.08(0.86) -1.00 0.92 -1.81 to 1.64 -0.014 SDQ- Hyperactivity 0.06(1.36) 0.04 0.96 -2.66 to 2.79 0.007 SDQ- Conduct Problems 0.16(1.87) 0.08 0.93 -3.61 to 3.93 0.012 SDQ- Peer Problems 3.63(1.83) 1.98 0.05* 0.04 to 7.31 0.255 SDQ- Prosocial Behaviour 2.02(1.05) 1.92 0.06 -0.08 to 4.14 0.254 Family Factors Biological Relative with OCD -1.44(1.64) -0.87 0.38 -4.74 to 1.85 -0.109 FAS- Mother Total -0.20(0.14) -1.39 0.17 -0.50 to 0.09 -0.160 FAS- Father Total 0.08(0.31) 0.26 0.79 -0.55 to 0.72 0.041 DASS Mother Total -0.11(0.11) -1.01 0.31 -0.34 to 0.11 -0.127 DASS Father Total -0.30(0.37) -0.82 0.41 -1.07 to 0.45 -0.131
Note: *p < .05; CY-BOCS: Children’s Yale Brown Obsessive Compulsive Scale; CGAS: Clinical Global Assessment Scale; BDI-Y: Beck Depression Inventory for Youth; DASS: Depression Anxiety Stress Scale; SDQ- Strengths and Difficulties Questionnaire- Parent Report; FAS: Family Accommodation Scale-Parent Report
29
Figure 1 Results of simple slopes analysis showing the association between SDQ Peer Problems
Scores and CYBOCS total post treatment for TCBT (r = -.42) and CBT (r = -.12).
30
Table 3 Associations between predictors and post-treatment CYBOCS total, with and
without control for pre-treatment CYBOCS
Variable Baseline CYBOCS Control
Unstandardized β (Standard Error)
t p Value 95% Confidence
Intervals
Correlations
Demographic Variables
Age at Assessment in Months
With 0.06 (0.03) 1.81 0.07 -0.00 to 0.14 0.214 Without 0.08(0.03) 2.36 0.02* 0.01 to 0.14 0.279
OCD-Related Variables
CYBOCS (baseline)
0.40(0.22) 1.83 0.07 -0.03 to 0.84 0.220
CGAS With -0.17(0.12) -1.36 0.17 -0.42 to 0.08 -0.162 Without -0.22(0.09) -2.21 0.03* -0.41 to -0.02 -0.263
Co-morbid Symptoms
SDQ-Emotional Symptoms
With 0.56(0.39) 1.45 0.15 -0.21 to 1.34 0.194 Without 0.63(0.39) 1.61 0.11 -0.15 to 1.41 0.218
SDQ-Peer Problems
With -1.70 (0.79) -2.14 0.03* -3.29 to 0.11 -0.281 Without -1.48(0.80) -1.83 0.07 -3.09 to 0.13 -0.247
SDQ-Prosocial Behaviour
With -0.61(0.49) -1.23 0.22 -1.61 to 0.38 -0.167 Without -0.78(0.48) -1.62 0.11 -1.75 to 0.18 -0.220
Family Factors FAS-Mother Total With 0.26(0.07) 3.43 0.00** 0.10 to 0.41 0.395
Without 0.27(0.07) 3.85 0.00** 0.13 to 0.42 0.443 FAS-Father Total With 0.17(0.11) 1.54 0.13 -0.05 to 0.40 0.232
Without 0.19(0.11) 1.73 0.09 -0.03 to 0.42 0.262
Note: *p < .05 **p < .01. CY-BOCS: Children’s Yale Brown Obsessive Compulsive Scale; CGAS: Clinical Global Assessment Scale; BDI-Y: Beck Depression Inventory for Youth; DASS: Depression Anxiety Stress Scale; SDQ-Strengths and Difficulties Questionnaire-Parent Report; FAS: Family Accommodation Scale-Parent Report